Gastrointestinal System (GI)

Gastrointestinal System

Physician Places Oral placement of GI tubes under imaging guidance (fluoroscopic) via the mouth or nose which ends in Stomach (Short NasoGastric Tube) or intestine (Long NasoEnteric Tube). some of the eg are mentioned below,

Nasogastric tubes, 

Dobhoff feeding tubes, 

Enteroclysis tubes, 

Blakemore tubes, and 

Miller-Abbott tubes

Short Nasogastric tube placement Procedure Description:

A nasogastric or orogastric tube is inserted through the nose or mouth of the patient into the stomach. The physician use radiological guidance (Fluoroscopic) to advance the tube into the stomach. The tube is connected to a syringe or a suction pump at the external open end to aspirate or drain the stomach contents.

CPT 43752 - Naso or orogastric tube placement, requiring physician's skill and fluoroscopic guidance (Procedure code includes fluoroscopy guidance) 

 

Long Nasoenteric tube placement Procedure Description:

The provider inserts a long flexible intestinal tube that consists of two channels and a balloon tip down to the small intestine. He uses one of the channels in the tube to aspirate, or withdraw, fluid and air for the temporary management of intestinal obstruction.   

The physician inserts a long gastrointestinal tube through the nose and down to the stomach. A weight in the tip of the tube helps maneuver the tube through the pylorus. The provider inflates the balloon which provides enough bulk to pass the tube into the small intestines. The provider sometime uses the CT or ultrasound to guide the insertion and assure placement of the tube. The provider then uses the second channel of the tube to aspirate, or withdraw, fluid and air from the intestines and relieve the obstruction. After an appropriate period of observation, the provider releases the patient.

CPT 44500 - Introduction of long gastrointestinal tube (eg, Miller-Abbott) 

S&I 74340 - Introduction of long gastrointestinal tube (eg, Miller-Abbott), including multiple fluoroscopic films with radiological supervision and interpretation.

CPT 43761 - Repositioning of a naso or orogastric feeding tube, through the duodenum for enteric nutrition, If imaging guidance is performed, use CPT 76000

GI TUBE PLACEMENT 

Gastrointestinal tube placement procedure involves percutaneous placement of a tube directly into the stomach or intestine via the skin.

 

Gastrostomy tube Procedure Description:

Patient is appropriately prepped and anesthetized, the physician inserts an orogastric or nasogastric tube and confirms the position by imaging. She insufflates, or blows air into, the stomach. Under fluoroscopic guidance punctures the abdominal wall and inserts a needle then passes a guide wire through it, and pulls the needle out. he places a dilator to allow serial dilatation of part of the body of the stomach. The physician advances a loop catheter into the stomach and injects contrast at each step to ensure proper placement of the tube and patency of the stomach. After securing the tube, he removes all instruments and applies sterile dressings.

CPT 49440 - Insertion of gastrostomy tube, percutaneous, under fluoroscopic guidance including contrast injection, image documentation and report.

 

Duodenostomy or jejunostomy tube Procedure Description:
Patient is appropriately prepped and anesthetized, the provider uses fluoroscopic guidance to puncture the abdominal wall. He inserts a needle, passes a guide wire through it, and pulls the needle out. He places a dilator to allow serial dilatation of the tract. He inserts and secures the jejunostomy or duodenostomy tube into the small intestine, stitching it in place. After securing the tube, he removes all instruments and applies sterile dressings.

CPT 49441 - Insertion of duodenostomy or jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection, image documentation and report 

Cecostomy Procedure Description:

Patient is appropriately prepped and anesthetized, the physician place a catheter in the rectum to inflate the colon during the procedure. The physician makes a small incision on the abdominal wall, assessing the position of the cecum or colon under fluoroscopic guidance. After identifying the position, he directly punctures the cecal or colon by inserting a needle and passes a guide wire through the needle under fluoroscopy. After removing the needle and performing dilatation of the tract, the provider inserts the cecostomy or colonic tube and secures it in the intestinal wall. He may inject contrast at each step to improve visualization under fluoroscopic imaging and ensure proper placement of the tube and patency of the cecum or colon. After completion of the procedure, he applies sterile dressings.

CPT 49442 - Insertion of cecostomy or other colonic tube, percutaneous, under fluoroscopic guidance including contrast injection, image documentation and report.

Note:

All percutaneous gastrointestinal tube placements include the use of Fluoroscopic, Injection of contrast, the images obtained, and the placement of the tube. No need to code S&I separately.

Conversion of gastrostomy tube to gastro-jejunostomy tube procedure description:

Patient is appropriately prepped and anesthetized, the provider uses fluoroscopy to guide placement of a guide wire through the existing gastrostomy tube. The physician removes the gastrostomy tube, uses the existing tract to advance a catheter, and then moves it across the pylorus and into the jejunum. The physician replace the guide wire with a stiffer wire and then use that wire to guide the gastrojejunostomy tube. The physician inject contrast to improve visualization under fluoroscopy and confirm proper tube position in both the jejunum and stomach. Then secures the tube and removes the wires. After completion of the procedure, applies sterile dressings.

CPT 49446 - Conversion of gastrostomy tube to gastro-jejunostomy tube, percutaneous, under fluoroscopic guidance including contrast injection, image documentation and report 

 

BILIARY SYSTEM

Percutaneous Transhepatic Cholangiography (PTHC)

PTHC is a diagnostic study that involves placement of a needle into the Bile duct of liver with Injection of contrast and obtaining imaging.

Procedure description:

Appropriately prepped and anesthetized the patient, the physician uses imaging guidance to pass a needle deep into the liver and into the common bile duct and administer a contrast agent then obtain diagnostic images of the bile ducts. After withdraws the needle, applies a sterile dressing at the site of insertion of the needle.

CPT Code : 47500 

         S&I  : 74320

47500-  Injection procedure for percutaneous transhepatic cholangiography.

74320-  Cholangiography, percutaneous, transhepatic, radiological supervision and interpretation. 

Don't use CPT 47500 for existing catheter cholangiography, Instead use CPT 47505. 

If the physician injecting contrast into the previously placed catheter then it would be appropriate to code CPT 47505 -  Injection procedure for cholangiography through an existing catheter with S&I 74305 - Cholangiography and/or pancreatography; through existing catheter, radiological supervision and interpretation

Biliary Tube Cholangiogram:
Its a Tube checking procedure, where contrast is injected through the previously placed biliary catheter

Biliary Drainage 

Biliary drainage is the insertion of a tube into the bile duct. This is most commonly carried out when the bile ducts are blocked.

External biliary drainage catheters can only drain externally and collected in Bag.

Internal and External biliary drainage catheters can drain externally and internally. 

External Biliary Drainage Procedure description: 

Patient is appropriately prepped and anesthetized and the physician uses imaging guidance to place a needle into the biliary tract that carries digestive juices from the liver, gallbladder, and pancreas to the intestines. Then passes a guide wire through the needle and then using the guide wire inserts a catheter into the bile duct. The physician uses the catheter for drainage of fluids and infected material.

CPT - 47510 - Introduction of percutaneous transhepatic catheter for biliary drainage.
S&I - 75980 - Percutaneous transhepatic biliary drainage with contrast monitoring, radiological supervision and interpretation

Internal and External Biliary Drainage Procedure description: 
Internal and External Biliary Drainage procedure is to drain bile both into the external connected bag as well as internally into the intestine.
Patient is appropriately prepped and anesthetized, the physician uses imaging guidance to place a needle into the biliary site. Then passes a guide wire through the needle and then using the guide wire inserts a balloon catheter into the bile duct. Then physician inflates the balloon to expand and clear the obstruction in the bile duct. The physician then removes the balloon catheter and inserts a stent to prevent the recurrence of obstruction in the bile duct. After the procedure, he ensures hemostasis.

CPT - 47511 - Introduction of percutaneous transhepatic stent for internal and external biliary drainage
S&I - 75982 - Percutaneous placement of drainage catheter for combined internal and external biliary drainage in patients with an inoperable mechanical biliary obstruction, radiological supervision and interpretation.

CPT Code 47511 states transhepatic stent for internal and external drainage. The term stent
refers to a catheter that extends from outside the body into the small bowl, Then stent which cannot be seen from outside assign CPT 47556

CPT 47556 - Biliary endoscopy, percutaneous via T-tube or other tract; with dilation of biliary duct stricture(s) with stent

If a Previously placed External biliary drainage tube is advanced into the duodenum, Use External and Internal Biliary Drainage catheter placement code 47511 with S&I code 75982.

Biliary Catheter Change

If the Biliary catheter is not functioning well or any complication is the indication for catheter change, The catheter is injected with contrast and imaging was obtained then the existing catheter is removed and replaced with a new catheter.

CPT - 47525 - Change of percutaneous biliary drainage catheter 

S&I  -75984 -  Change of percutaneous tube or drainage catheter with contrast monitoring, radiological supervision and interpretation

Biliary Catheter Revision 

 The physician remove and reinsert the same catheter its appropriate to code CPT 47530 - Revision and/or reinsertion of transhepatic tube and S&I code - 75984 (Change of percutaneous tube or drainage catheter with contrast monitoring, radiological supervision and interpretation )

 

GENITOURINARY SYSTEM (GU)

Non Vascular Interventional Coding

Genitourinary System (GU)

      There are various non vascular Interventional procedures are performed for various conditions which are related to GU system are mentioned below, some of the common Terminology are:

Pyelography:  X ray images of the renal pelvis of the kidney with associated structures after administration of a contrast agent.

Nephrostomy tube:  A very small, soft, plastic tube, which is placed into the renal collecting system for temporary drainage of urine, abscess, or calculus removal.

Pyelostomy tube:   A plastic tube which is placed in the renal pelvis of the kidney for drainage of urine. It is placed either percutaneously or during an open surgical procedure.

Nephrostogram:   An X ray of the kidney after injection of a contrast agent.

Pyeloureterogram:  An X ray of the kidneys, renal pelvis, and ureters after injection of a contrast agent.

Percutaneous Antegrade Pyelogram

A Percutaneous Antegrade Pyelogram  is performed by placing a needle into the kidney or kidney cyst with injection of contrast and taking images.

 CPT 50390- Aspiration and/or injection of renal cyst or pelvis by needle, percutaneous
 For radiological S&I, - 74425,74470, 76942, 77002, 77012, 77021. 

Note:
Don't assign antegrade pyelogram if contrast injection was performed for the purpose of
localization of a posterior calyx for subsequent Percutaneous nephrostomy tube placement.

Nephrostomy Tube Placement

Renal collecting system obstruction would be the major reason behind the placement of Percutaneous nephrostomy tube placement. The procedure consist of placement of a drainage tube into the collecting system of an obstructed kidney. The tube is sutured in place and drains to a bag at the patient’s side.

CPT 50392 - Introduction of intracatheter or catheter into renal pelvis for drainage and/or injection, percutaneous

For radiological S&I, - 74475, 76942, 77012

Note:
If both a diagnostic antegrade pyelogram and a nephrostomy tube placement are performed at
the same session, code 50392 and 50390 with 59 modifier along with appropriate S&I codes.

(The diagnostic antegrade pyelogram is via the initial needle puncture of the collecting system, followed by a new separate percutaneous puncture of a posterior calyx for placement of the drainage catheter)

Nephrostogram

Malfunctioning drainage tube or any complication would be the reason for Nephrostogram procedure following prior Percutaneous nephrostomy tube placement. Nephrostogram involves injection of contrast into a newly placed or pre-existing kidney drainage tube and analyze the internal structures of the kidney, renal pelvis, and/or ureter using imaging guidance.

 

CPT 50394 - Injection procedure for pyelography (as nephrostogram, pyelostogram, antegrade pyeloureterograms) through nephrostomy or pyelostomy tube, or indwelling ureteral catheter

 

For radiological S&I, - 74425

 

Note:  If a tube check or change is performed with the patient in the supine position, it is  via an ileal conduit and is coded with 50684 or 50688.

 

           If a tube check or change is performed with the patient in the prone position, the procedure is performed via flank and is coded with 50394. 

 

Nephrostomy Tube change

Non-functioning nephrostomy tube is the reason behind the Nephrostomy Tube change, Nephrostomy tube is evaluated first by administrating contrast through the existing Nephrostomy Tube (NEPHROSTOGRAM) and The exchange portion of the exam occurs when a wire is placed through the existing tube and the tube is removed, followed by placement of a new tube into the kidney over the wire.

 

CPT 50398 - Change of nephrostomy or pyelostomy tube

 

For radiological S&I, - 75984

 

Note: In case contrast was not documented don't assign 75984 instead can code 76000.